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There are more treatment options available for ADHD than ever before. Which ones are people using, and are they finding them effective? We wanted to find out the answers, so we asked you, our readers, in an exclusive ADDitude survey. What we discovered from the more than 4,000 responses challenges our assumptions about how people are actually treating their ADHD in 2017.

By Devon Frye, Anni Layne Rodgers

ADHD is a complex and nuanced condition, with symptoms varying widely from distractibility to excessive activity and many points in between. The average treatment plan, it seems, is correspondingly complex.

A recent survey of more than 4,000 ADDitude readers shows us that adults and parents treating ADHD typically try multiple treatment options and continue to tinker with the overall plan years, or decades, after being diagnosed. No single medication, therapy, or dietary and supplement regimen works for all individuals with ADHD. What’s more, the treatments that our readers told us work best aren’t always the ones recommended by their doctors or used by the most people.

Getting to the right treatment plan is complicated and affected by economics, geography, and access to information. Survey respondents also suggest that ADHD treatment plans may be shaped by factors like insurance coverage, lifestyle changes, budgets, and side effects.

“Everyone with ADHD is different — reacts to different treatment modalities differently, reacts differently to drugs,” one mother wrote in the survey. “For some, it’s straightforward. For others — like us — it is frustrating, at best.”

The trial and error of treatment feels like “a full-time job,” our readers said. ADHD medications, many of which are controlled substances, often require multiple doctor’s visits, frequent refills, and expensive copays — “and that’s with insurance,” one parent wrote. Non-medication options, like coaching or neurofeedback, are not available outside of many metropolitan areas — and if they are, they’re often not covered by insurance, leading respondents to “not try things because we couldn’t afford to.”

Patients also reported having to research comprehensive treatment plans on their own, and this is not easy. For the most part, respondents received little expert information about treatment options beyond medication, which was recommended by 92 percent of our respondents’ medical professionals.

For example, the American Academy of Pediatrics (AAP) recommends behavior therapy paired with medication for all children with ADHD over the age of six. Yet fewer than one-third of the ADDitude caregivers surveyed said their doctors prescribed behavior therapy. According to the survey, 59 percent of children with ADHD are not receiving this recommended form of treatment.

Similarly, exercise was rated as “extremely” or “very” effective by roughly half of the respondents who use this treatment. Yet only 13 percent of these respondents said a doctor had recommended exercise to reduce symptoms, and only 37 percent of all respondents said physical activity was part of their treatment plan.

In the end, despite combining medication and lifestyle changes, researching and self-funding treatments not covered by insurance, and continually revisiting their treatment plans, overall satisfaction rates were low. Indeed, only 30 percent of caregivers called their child’s treatment plan “extremely” or “very” effective. Likewise, just 44 percent of adults surveyed were satisfied with their ADHD treatment. Here, we will analyze the survey data for reasons why this is true, and look for a better way forward.

ADHD Treatment Snapshot

Percent of Survey Respondents Currently Using Each Therapy

Children

Adults

Prescription Medication

67%

70%

Vitamins, Minerals, or Supplements

36%

41%

Exercise

37%

37%

Diet/Nutrition Plan

29%

28%

ADHD Coaching/Counseling

26%

21%

Mindfulness/Meditation

13%

35%

Cognitive Behavioral Therapy (CBT)

—

19%

Behavioral Therapy/Parent-Training Classes

10%

—

Neurofeedback with a Clinician

5%

3%

Home-Based Brain Training

3%

2%

ADHD Treatment Ratings

Percent of Survey Respondents Who Rated Each Therapy Extremely or Very Effective

Children

Adults

Prescription Medication

41%

40%

Vitamins, Minerals, or Supplements

12%

15%

Exercise

49%

56%

Diet/Nutrition Plan

25%

33%

ADHD Coaching/Counseling

33%

48%

Mindfulness/Meditation

27%

42%

Cognitive Behavioral Therapy (CBT)

—

41%

Behavioral Therapy/Parent-Training Classes

33%

—

Neurofeedback with a Clinician

30%

42%

Home-Based Brain Training

22%

14%

About the Survey

In August 2017, we sent the “My ADHD Treatment Plan” survey to a group of ADDitude newsletter subscribers. Among the 4,425 respondents, 2,495 were parents reporting on a child, and 1,563 were adults focused on their own treatment. Boys comprised 74 percent of the children, while 75 percent of the adults reporting on their treatment plans were women. Subjects ranged in age from four to older than 65; most children were diagnosed between the ages of five and eight, while 44 percent of adults were diagnosed after the age of 40.

Find complete information about the survey and the resulting data at https://www.additudemag.com/2017-adhd-treatment-survey-findings/

Medication

Exercise. Behavior training classes. ADHD coaching and counseling. These are the treatments rated most effective by caregivers and adults with ADHD, according to our survey. All three — plus meditation, neurofeedback, and CBT — ranked higher than did medication for efficacy. Yet, despite the middling effectiveness rating for medication — and the occasional glowing review — our respondents used it far more than any other treatment. Why? Convenience factored heavily — particularly when considering the time commitment associated with therapy or lifestyle changes. But medication’s main advantage may be the tangible, immediate changes it can bring — and for those struggling with symptoms on a daily basis, any concrete improvement can feel like a lifesaver.

That said, finding the most effective medication with the fewest side effects was not usually a quick or easy process. Most survey respondents tried a number of medications before finding one that worked — 2.7 medications, on average, for caregivers; 3.5 for adults. You must be “patient and willing to go through trial and error,” wrote an adult who tried Ritalin, Adderall, and Evekeo before settling on Vyvanse. “Once you find it, it will do so much in improving symptoms.”

Another group of survey respondents (16 percent of caregivers; 18 percent of adults) reported that they had used medication in the past but had stopped taking it altogether. This decision was usually because of persistent side effects. Among the most common were:

Loss of appetite: experienced by 58 percent of children and 35 percent of adults surveyed

Irritability: experienced by 34 percent of children and 24 percent of adults surveyed

Sleep disturbances: experienced by 28 percent of children and 23 percent of adults surveyed

The Medication Decision

Parents too often face criticism for “jumping on the medication bandwagon.” In reality, only 14 percent of caregivers said they viewed medication as the “first-line” treatment for their child’s ADHD symptoms; an equal number said medication was their “last resort” — and an additional 20 percent said they tried other treatment options before deciding to pursue medication.

“It’s not that I don’t think the other treatments will work at all,” one parent wrote. “It’s that we think medication will have quicker results, work better, and [work] more consistently.” Medication has “worked wonders” for her daughter for 14 years, she wrote.

Adults were generally far less reluctant to try medication, and more likely to view it in a more positive light. About a third of adults saw medication as their “first-line” treatment; less than 5 percent said it was their last resort. Only 9 percent said they tried something else before trying medication, and 51 percent see medication as life-changing. “I don’t know how I survived without it all of these years,” wrote one person. “It’s like someone switched on a light.”

Those who turned quickly to medication frequently cited its “ease” and immediacy — a doctor’s prescription was easily filled and any effects (positive or negative) were usually noticeable right away. “I wanted to get my son’s symptoms under control quickly,” said one caregiver. “Medication seemed like a good first-line attack for that.”

Others said they were at their wits’ ends. “Getting [my daughter] to do anything was a struggle,” wrote one parent. “I took her to a psychologist who suggested medication. I was 100 percent on board — I would say I was desperate to find something to work.”

Other parents said they changed their minds about medication because other treatments failed to ameliorate symptoms. One caregiver, who reported trying vitamins, behavior therapy, and neurofeedback before settling on medication, said: “I don’t want to give him medicine to make him feel ‘normal’ — but he cannot function without it.” Some parents never feel at ease with their decision. “It terrifies me,” one parent wrote. “I only give it to him during school — no weekends or summer.”

Vitamins, minerals, and supplements were the most popular non-medication treatment among our survey respondents, 47 percent of whom said they had tried at least one. Of that group, fish oil was the top choice (used by 77 percent), followed by magnesium and vitamin B6. Yet only 17 percent of people said their doctors had recommended supplements.

Despite their relative popularity, vitamins ranked as the least effective treatment for children and the second least effective for adults. More than a third of caregivers and adults called them “not very” or “not at all” effective. When it came to fish oil, in particular, adults complained of having to take “huge” doses to see any benefits, and parents struggled to get kids to swallow large capsules or to get beyond the “fishy” taste. Many parents stopped this treatment, in part, because they could not find a formulation that worked and/or they could not tell whether it was helping. “The fish oil did help my son,” one parent wrote, but, “he got tired of the taste of both of the kinds we tried and didn’t want to take them anymore.”

High-quality fish oil, like other supplements, can be expensive, respondents said. “I didn’t see much bang for the buck with this treatment — and it was a lot of bucks,” wrote one man in his 30s. The high costs made him abandon the treatment quickly — an experience echoed by others.

Top Non-Medication Treatments Used for ADHD Symptoms

Children

Adults

Vitamins, Minerals or Supplements

36%

41%

Exercise

37%

37%

Diet/Nutrition Plan

29%

28%

Top Vitamins, Minerals, and Supplements Used to Treat ADHD Symptoms

The following numbers represent the percentage of people using each specific treatment among the subset of survey respondents who said they are using vitamins, minerals, or supplements.

Children

Adults

Fish Oil

80%

76%

Magnesium

29%

41%

Vitamin B6

23%

41%

Top Diet/Nutrition Strategies Used to Treat ADHD Symptoms

The following numbers represent the percentage of people using each specific treatment among the subset of survey respondents who said they are diet and nutrition strategies.

Children

Adults

Decreasing/eliminating artificial colors/dyes

70%

53%

Decreasing/eliminating sugar

66%

75%

Increasing protein

61%

69%

Decreasing/eliminating artificial flavors

51%

48%

Top Reasons Why Non-Medication ADHD Treatments Were Not Tried

Children

Adults

Not covered by insurance/high cost

29%

28%

Hard to find professionals

24%

25%

Wasn’t aware of other treatments

11%

22%

Medication alone works well enough

10%

20%

Exercise

Exercise ranked as the most effective ADHD treatment among both caregivers and adults — 49 percent and 56 percent of whom gave it high marks, respectively. That is not a surprise. Research shows that exercise elevates dopamine and norepinephrine levels in the brain, thus boosting focus, self-control, and mood. Despite the solid science and high satisfaction levels, however, our survey shows that only 37 percent of children and adults with ADHD are managing their symptoms with daily exercise.

The respondents who exercise said they do so to benefit their general health, not just their ADHD symptoms. But its mood-boosting and sleep-inducing effects, in particular, were popular. “Exercise allows me to drain my brain,” said one adult. “When I leave the gym, my brain is happy, content, and not going in all different directions.” Parents, too, notice behavior improvements associated with exercise. One mother reported, “I can tell by his behavior when my son does not get enough active outdoor time.”

Behavior Therapy

The AAP recommends behavior therapy as the first-line treatment for children younger than six, and using it in conjunction with medication for older children — and 41 percent of our survey respondents had completed a parent-training course. Those who did liked that it gave them more “tools” as parents and, due to the group setting of many programs, the realization that they were not alone.

Still, why did less than half of the caregivers we surveyed use this AAP-recommended treatment? One-third reported difficulty finding a practitioner in their area; another 34 percent were deterred by inadequate insurance coverage or a high out-of-pocket cost. Only 9 percent said that they didn’t seek behavior therapy because they felt it wasn’t needed.

“It’s hard to find the proper counselor,” one parent wrote. “Many don’t take insurance, and the time commitment to bring him made therapy very inconvenient.” One parent wrote of a 90-minute car trip to take her child to a therapist each week; another wrote that insurance covered only five sessions — and paying for more out of pocket was unaffordable.

In addition, effectiveness “entirely depends on the program and the support given to parents,” wrote the mother of a teen. That thought was held by others: Behavioral therapy was primarily positive (33 percent rated it “extremely/very” effective) — when it was available — but an ADHD-specific program is critical to success.

Treatment Is a Journey

Our survey results indicate that ADHD treatment is neither streamlined nor satisfying for most families and individuals. Most of our respondents conducted their own treatment research, cast wide nets, and combined multiple strategies — and, even then, felt satisfied less than half the time. Many described the process as “a moving target” or “a work in progress” — even if their journey began years or decades earlier.

While some respondents did report satisfaction with their treatment plan, many reported that the process can seem arbitrary, complicated, and overwhelming — in large part because treatment almost never comprises just one modality. Though caregivers and adults face no shortage of options, each has its own upsides and drawbacks.

Diet and Nutrition

More than a quarter of respondents have used dietary changes to address ADHD symptoms (with higher rates in those who had never tried medication). Decreasing or eliminating sugar was the most popular choice, followed by eliminating artificial dyes and increasing protein.

Many caregivers reported struggling to make dietary changes stick. “We tried working with a nutritionist, but our child simply wouldn’t follow the diet,” wrote one parent. “She tends to eat carbs and sweets, and wouldn’t realize how often she strayed from the diet.”

Mindful Meditation

Mindfulness is used by 35 percent of adults with ADHD, but just 13 percent of children. The satisfaction rate among adults who use meditation is high, with 42 percent rating it as highly effective. Many cited mood boosts, improved executive functioning, and decreased anxiety as benefits of this therapy.

“Meditation is a critical part to starting the day!” wrote one adult. “Taking a few moments to ground yourself before your ADHD brain races off works wonders.”

Coaching & Counseling

Twenty-six percent of caregivers and 21 percent of adults reported experience with ADHD coaching or counseling. For adults, this was the second most effective treatment; more than 48 percent rated it as “extremely” or “very” effective. Caregivers also viewed it generally positively, with more than a third rating it highly.

However, “Finding the right personality is key,” said one parent. “And my daughter doesn’t always want to follow the coach’s advice.”

Brain Training and Neurofeedback

Very few respondents use neurofeedback and home-based brain training (5 percent or less in both populations), with slightly higher rates in parents and adults who had never medicated.

Neurofeedback was rated well by 30 percent of parents and 42 percent of adults — meaning that, while it was barely used, it ranked higher in effectiveness than several more popular treatments. Still, among parents and adults as a whole, home-based brain training wasn’t well reviewed: just 22 percent of parents and 14 percent of adults rated it highly, and one called it “just a glorified video game.”

Complex post-traumatic stress disorder (CPTSD) occurs with repeated ongoing exposure to traumatic events. Often CPTSD is a result of early traumatic relationships with caregivers. In this article we consider the effects of early traumatic relationships on learning.

Many children with a history of trauma have trouble with learning in the classroom and do not perform as well as their peers. The connection between early interpersonal trauma and learning is particularly relevant when considering the ability to maintain attention and concentration. Often, early traumatic relationships impair more than emotion regulation abilities. Cognitive capacities are also deeply affected since the ability to focus and concentrate is largely dependent upon emotion regulation.

Early attachment relationships and learning

Early relationships have a direct impact on cognitive, social and emotional development. This is because an infant/child who is raised in a safe and supportive environment has ample opportunity for exploration as well as the availability of comfort from a trusted caregiver.

One of the ways infants learn is through play and exploration of their environment. When thinking about this stage of development it is crucial to understand that an infant’s biological system is not mature enough to calm itself in times of fear or upset. This is why young children and infants reach for a trusted adult when they feel fear or uncertainty. In a secure relationship, opportunities abound for curiosity and exploration. At the same time, the infant is protected from unhealthy levels of stress, when he/she needs comfort, it is available.

Attachment researchers call this phenomenon a “secure base” in which the caregiver encourages the child to lay, with providing safety and security for the infant when needed. Exploratory play coupled with protection provide an optimal environment for learning. Researchers have noted traumatized infants tend to spend less time in exploratory play (Hoffman, Marvin, Cooper & Powell, 2006).

An example

Let’s imagine a young child in a playground. She is less than a year old and not quite walking on her own yet. With mom nearby she can explore, perhaps by playing in the sandbox and learning how her toy car moves differently over sand in comparison to the kitchen floor at home. She is learning important information about the world. While she plays while she is keeping an eye on mom, making sure she is near. If anything happens to cause fear, perhaps a big dog strays onto the playground, a predictable scenario plays out. The child begins to cry, afraid of the dog. Mom is here to help. She picks up her infant and soothes her distress, walks away from the animal, and relatively soon, the infant is calm again.

In a traumatic relationship, mom may not recognize she needs to help her child. She may not be afraid of dogs and does not understand the infant’s reaction. She may decide to let the infant learn about dogs without her help. Perhaps the child gets bit by the dog or is allowed to scream frantically while the big, unfamiliar animal investigates her, and still mom does not react in an appropriate calming way. She may let her child learn the dog is safe (or not safe) without getting involved. Alternatively, she may escalate the situation with her own fear of dogs and scare the child even more.

In terms of emotional and cognitive development, these two infants are dealing with very different internal and external environments. Internally, the traumatized infant’s developing nervous system is exposed to ongoing heightened states of stress hormones that circulate through the developing brain and nervous system. Since the infant is left on her own to recover from a traumatic event, all of her resources are required to bring herself back to a state of balance. Researchers in the field of neuropsychology have pointed out that when an infant is required to manage its own stress without help, he or she can do nothing else (Schore, 2001). All energies are dedicated to calming the brain and body from significant stress. In this situation, valuable opportunities for social and cognitive learning are lost.

It is important to understand that all parents at some time fail to soothe their child when he/she is distressed. Healthy children do not require perfect parenting; it is the continued ongoing trauma that is detrimental to development.

Hypervigilance — The impact of early traumatic relationships in the classroom

Children raised in violent or emotionally traumatic households often develop hypervigilance to environmental cues. More than just a “common sense” response to an abusive environment, hypervigilance occurs because of the way the nervous system has organized itself in response to persistent fear and anxiety during the earliest years of development (Creeden, 2004). Hypervigilance to other’s emotional cues is adaptive when living in a threatening environment. However, hypervigilance becomes maladaptive in the classroom and impedes the child’s ability to pay attention to school work. For the traumatized child, school work may be thought of as irrelevant in an environment that requires attention dedicated to physical and emotional protection of self (Creeden, 2004).

An example

Imagine a time when you were very upset or unsure of your physical or emotional safety. Perhaps an important relationship is threatened after a particularly heated argument and you feel you are at a loss of how to fix it. Imagine you had a violent encounter with a parent, or are dealing with sexual abuse at home. Now imagine, in this situation, trying to focus your attention on the conjugation of verbs, or long division. It is likely you would find this impossible.

What can be done?

It’s important that we understand the roots of learning and behavioral difficulties in the classroom so we can address them with therapy rather than prescribing medications (Streeck-Fischer, & van der Kolk, 2000). Some children who cannot focus in the classroom may be wrongly diagnosed and never offered the help they need.

There are effective ways to help children with past trauma in their learning environments. Adults need to understand that for a traumatized child, challenging behaviors are rooted in extreme stress, inability to manage emotion, and inadequate problem solving skills (Henry et al, 2007). In these circumstances, the child will likely respond more positively to a non-threatening learning environment. Children with traumatic histories need the opportunities to build trust and practice focusing their attention on learning rather than survival. A supportive environment will allow for safe exploration of the physical and emotional environment. This strategy applies to children of various ages. Older children also need to feel safe in the classroom and when working with adults such as teachers and other professionals. Frustrated teachers may believe children with challenging behaviors are hopeless and just not interested in learning. The teacher may insult the child, respond with sarcasm or just give up on the child. Teachers may fail to protect the child from teasing or ridicule from their peers. In this way, the teacher is also contributing to the threatening environment the child has come to expect.

New understanding, new opportunities

A shift in understanding is required for teachers and other professionals working with traumatized children in the classroom. Supportive environments can give these children a chance to modify their behavior and develop coping skills. This change in adult’s perception of why the child is unable to focus on schoolwork will hopefully lead to a change in attitude.

Even more importantly, children with trauma in their early history are in need of therapy and support. With understanding and appropriate therapeutic intervention, these children will have a much better chance at healing past trauma and developing the ability to focus, learn in the classroom and respond differently to challenging situations.

The mission of Mental Health Associates is to provide the highest quality mental health services, with a commitment to each individual at any stage of their life, and to provide research-based therapeutic services by highly trained and independently licensed professionals.